Express Scripts, Inc. NCPDP Version D.0 Payer Sheet Commercial

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
IMPORTANT NOTE: Express Scripts is currently accepting NCPDP Version D.0 electronic
transactions. This documentation is to be used for programming the fields and values
Express Scripts will accept when processing these claims.
Claim transaction segments not depicted within this document may be accepted during the
transmission of a claim. However, Express Scripts may not use the information submitted
to adjudicate claims. All values submitted will be validated against the NCPDP External
Code List version as indicated below.
General Information:
Payer Name: Express Scripts, Inc. Date: March 1, 2013
Plan Name/Group Name: Express Scripts, Inc. - Standard Plan - Exceptions Noted
Processor: Express Scripts, Inc.
Switch:
Effective as of: March 1, 2013 Version/Release Number: D.0
NCPDP Data Dictionary Version Date: October 2011 NCPDP External Code List Version Date: October 2011
NCPDP Emergency External Code List Version Date:
July 2012
Contact/Information Source: Network Contracting & Management Account Manager, or
(800) 824-0898, or Express-Scripts.com
Testing Window: As determined by testing coordinator
Pharmacy Help Desk Info: (800) 824-0898
Other versions supported: N/A
―Materials Reproduced With the Consent of
©National Council for Prescription Drug Programs, Inc.
2008 NCPDP‖
Section I: Claim Billing (In Bound)
Transaction Header Segment - Mandatory in all cases
Field # NCPDP Field Name Value Payer Usage
1Ø1-A1 BIN Number ØØ3858 (or as assigned by ESI) M
1Ø2-A2 Version Release Number DØ=Version D.0 M
1Ø3-A3 Transaction Code B1=Billing M
1Ø4-A4 Processor Control Number PCN= A4 (or as assigned by ESI)
M
PCN= SC: Use when secondary to Medicare D only
1Ø9-A9 Transaction Count 1=One Occurrence
M
2=Two Occurrences
3=Three Occurrences
4=Four Occurrences
2Ø2-B2 Service Provider ID Qualifier Ø1=NPI M
2Ø1-B1 Service Provider ID Pharmacy or Dispensing Physician NPI M
4Ø1-D1 Date of Service M
11Ø-AK Software Vendor/Certification ID M
1
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Insurance Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification Ø4=Insurance M
3Ø2-C2 Cardholder ID ID assigned to the cardholder M
312-CC Cardholder First Name R
313-CD Cardholder Last Name R
524-FO Plan ID R*
3Ø9-C9 Eligibility Clarification Code Ø=Not Specified
R
1=No Override
2=Override
3=Full Time Student
4=Disabled Dependent
5=Dependent Parent
6=Significant Other
3Ø1-C1 Group ID As appears on card R
3Ø3-C3 Person Code P1-P9
R
Dependent person code (1-9 represents specific
dependent; maximum of 9 dependents)
3Ø6-C6 Patient Relationship Code Ø=Not Specified
1=Cardholder – The individual that is enrolled in and
receives benefits from a health plan
2=Spouse – Patient is the husband/wife/partner of
the cardholder
3=Child – Patient is a child of the cardholder
4=Other – Relationship to cardholder is not precise
R
Patient Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification Ø1=Patient M
331-CX Patient ID Qualifier O
332-CY Patient ID As indicated on member ID card O
3Ø4-C4 Date of Birth R
3Ø5-C5 Patient Gender Code 1=Male
R
2=Female
31Ø-CA Patient First Name Example: John R
311-CB Patient Last Name Example: Smith R
322-CM Patient Street Address O
323-CN Patient City O
324-CO Patient State or Province O
325-CP Patient Zip/Postal Code RW
Emergency/Disas
ter Situations;
include current
ZIP code of
displaced patient
3Ø7-C7 Place of Service Ø1 = Pharmacy R
384-4X Patient Residence R
2
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Claim Segment – Mandatory (Payer does not support partial fills)
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification Ø7=Claim M
455-EM
Prescription/Service Reference
Number Qualifier
Ø1=Rx Billing
*Pharmacist should enter a ―1‖ when processing
claim for a vaccine drug and vaccine administration
4Ø2-D2 Prescription/Service Reference
M
Number
436-E1 Product/Service ID Qualifier ØØ=Not Specified*
M
Ø3=National Drug Code
4Ø7-D7 Product/Service ID* M
442-E7 Quantity Dispensed R
4Ø3-D3 Fill Number Ø=Original Dispensing
R
1 to 99 = Refill number
4Ø5-D5 Days Supply R
4Ø6-D6 Compound Code 1=Not a Compound
2=Compound*
4Ø8-D8
Dispense as Written
(DAW)/Product Selection Code
Ø=No Product Selection Indicated -This field
default value is appropriately used for prescriptions
for single source brand, co-branded/co-licensed or
generic products. For a multi-source branded
product with available generic(s), DAWØ is not
appropriate and may result in a reject.
1=Substitution Not Allowed by Prescriber -This
value is used when prescriber indicates, in a
manner specified by prevailing law, that the product
is Medically Necessary to be Dispensed As Written.
DAW1 is based on prescriber instruction and not
product classification.
2=Substitution Allowed-Patient Requested Product
Dispensed - This value is used when prescriber
has indicated, in a manner specified by prevailing
law, that generic substitution is permitted and the
patient requests the brand product. This situation
can occur when the prescriber writes the
prescription using either the brand or generic name
and the product is available from multiple sources.
3=Substitution Allowed-Pharmacist Selected
Product Dispensed -This value is used when
prescriber has indicated, in a manner specified by
prevailing law, that generic substitution is permitted
and the pharmacist determines that the brand
product should be dispensed. This can occur when
the prescriber writes the prescription using either
3
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖
M
R
*Requires the
compound
segment be sent
R

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
the brand or generic name and the product is
available from multiple sources.
5=Substitution Allowed-Brand Drug Dispensed as a
Generic -This value is used when prescriber has
indicated, in a manner specified by prevailing law,
that generic substitution is permitted and the
pharmacist is utilizing the brand product as the
generic entity.
7=Substitution Not Allowed-Brand Drug Mandated
by Law -This value is used when prescriber has
indicated, in a manner specified by prevailing law,
that generic substitution is permitted but prevailing
law or regulation prohibits substitution of a brand
product even though generic versions of the
product may be available in the marketplace.
414-DE Date Prescription Written R
415-DF Number of Refills Authorized Ø=No refills authorized
R
1 through 99, with 99 being as needed, refills
unlimited
419-DJ Prescription Origin Code Ø=Not known
1=Written
2=Telephone
3=Electronic
4=Facsimile
5=Pharmacy
R
354-NX
Submission Clarification Code
Count
Maximum count of 3
4
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖
RW
(Submission
Clarification
Code (42Ø –
DK) is used)
42Ø -DK Submission Clarification Code RW
(Clarification is
needed and
value submitted
is greater than
zero Ø). The
value of 2 is
used to
respond to a
Max Daily
Dose/High
Dose Reject.)
3Ø8-C8 Other Coverage Code Ø=Not specified by patient
1=No other coverage
2=Other coverage exists - payment collected**
3=Other coverage billed - claim not covered**
4=Other coverage exists - payment not collected**
8=Claim is billing for patient financial responsibility
only**
R

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
6ØØ-28 Unit of Measure EA=Each
GM=Grams
ML=Milliliters
418-DI Level of Service Ø=Not specified
1=Patient consultation (professional service
involving provider/patient discussion of disease,
therapy or medication regimen or other health
issues)
2=Home delivery—provision of medications from
pharmacy to patient’s place of residence
3=Emergency—urgent provision of care
4=24-hour service—provision of care throughout
the day and night
5=Patient consultation regarding generic product
selection—professional service involving
discussion of alternatives to brand-name
medications
6 =In-Home Service—provision of care in patient’s
place of residence
461-EU Prior Authorization Type Code Ø=Not specified
1=Prior Authorization
9=Emergency Preparedness***
462-EV Prior Auth Number Submitted Submitted when requested by processor.
Examples: Prior authorization procedures for
physician authorized dosage or day supply
increases for reject 79 'Refill Too Soon'.
O
O
RW
(462-EV is
used)
RW
(461-EU is
equal to 1 or 9)
357-NV Delay Reason Code RW
(Needed to
specify the
reason that
submission of
the transaction
has been
delayed)†
995-E2 Route of Administration RW
(Required for
Compounds)
147-U7 Pharmacy Service Type Ø1= Community/Retail Pharmacy Services
Ø3= Home Infusion Therapy Services
Ø5= Long Term Care Pharmacy Services
*The Product/Service ID (4Ø7-D7) must contain a value of ―Ø‖ and Product/Service ID Qualifier (436-E1) must contain
a value of ―ØØ‖ when used for multi-ingredient compounds.
**Requires the COB segment to be sent.
***For value ―9=Emergency Preparedness‖ Field 462-EV Prior Authorization Number Submitted supports the following
values when an emergency healthcare disaster has officially been declared by appropriate U.S. government agency.
911ØØØØØØØ1 Emergency Preparedness (EP) Refill Too Soon Edit Override
†All values are accepted. Values of 1, 2, 7, 8, 9, 10 may be allowed to override Reject 81 (Claim Too Old) for member
claims UPGRADED to the new adjudication system.
R
5
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Pricing Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 11=Pricing M
4Ø9-D9 Ingredient Cost Submitted R
412-DC Dispensing Fee Submitted R
433-DX Patient Paid Amount Submitted O
438-E3 Incentive Amount Submitted RW
(Value has an
effect on
Gross Amount
(43Ø-DU)
calculation)
481-HA Flat Sales Tax Amount Submitted RW
(Value has an
effect on
Gross Amount
(43Ø-DU)
calculation)
482-GE
483-HE
484-JE
Percentage Sales Tax Amount
Submitted
Percentage Sales Tax Rate
Submitted
Percentage Sales Tax Basis
Submitted
6
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖
RW
(Value has an
effect on
Gross Amount
(43Ø-DU)
calculation)
RW
(Percentage
Sales Tax
Amount
Submitted
(482-GE) and
Percentage
Sales Tax
Basis
Submitted
(484-JE) are
used)
RW
(Percentage
Sales Tax
Amount
Submitted
(482-GE) and
Percentage
Sales Tax Rate
Submitted
(483-HE) are
used)
426-DQ Usual and Customary Charge R
43Ø-DU Gross Amount Due R
423-DN Basis of Cost Determination R

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Prescriber Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification Ø3=Prescriber M
466-EZ Prescriber ID Qualifier Ø1=NPI
R
Ø8=State License
12=DEA (Drug Enforcement
Administration)
411-DB Prescriber ID NPI* R
427-DR Prescriber Last Name RW
(Prescriber ID Qualifier
(466-EZ) =Ø8)
367-2N Prescriber State/Province
Address
RW
(Prescriber ID Qualifier
(466-EZ) = Ø8, 12)
Express Scripts edits the qualifiers in field 466-EZ. A valid Prescriber ID is required for all claims. Claims unable to be
validated may be subject to post-adjudication review.
* For vaccines, an individual NPI is required. It may be the prescriber who wrote the prescription or alternate care
provider (pharmacist, nurse practitioner, etc.) who administered the vaccine.
Coordination of Benefits/Other Payments Segment – Situational
(Will support only one transaction per transmission)
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification Ø5=COB/Other Payments M
337-4C Coordination of Benefits/Other Maximum count of 3
M
Payments Count
338-5C Other Payer Coverage Type M
339-6C Other Payer ID Qualifier Ø3=BIN
Ø5=Medicare Carrier Number
7
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖
RW
(Other Payer ID
(34Ø-7C) is
used)
34Ø-7C Other Payer ID R
443-E8 Other Payer Date R
341-HB Other Payer Amount Paid Count R
342-HC Other Payer Amount Paid
Ø7=Drug Benefit
R
Qualifier
1Ø=Sales Tax
431-DV Other Payer Amount Paid Valid value of greater than $Ø to reflect sum of
R
Other Payer Amount Paid Qualifier
471-5E Other Payer Reject Count Maximum count of 5 RW (Other
Payer Reject
Code (472-6E)
is used)
472-6E Other Payer Reject Code RW (Other
Payer Reject

353-NR
351-NP
352-NQ
Other Payer – Patient
Responsibility Amount Count
Other Payer – Patient
Responsibility Amount Qualifier
Other Payer – Patient
Responsibility Amount
Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Maximum count of 13
Count (471-5E)
is used)
RW (Other
Payer-Patient
Responsibility
Amount
Qualifier (351-
NP) is used)
RW (Other
Payer-Patient
Responsibility
Amount (352-
NQ) is used)
RW (Necessary
for Patient
Financial
Responsibility
Only Billing)
392-MU Benefit Stage Count Maximum count of 4 RW
(Secondary to
Medicare)
393-MV Benefit Stage Qualifier Occurs up to 4 times RW
(Secondary to
Medicare)
394-MW Benefit Stage Amount RW
(Secondary to
Medicare)
The COB segment and all required fields must be sent if the Other Coverage Code (3Ø8-C8) field with values = 2 through 4
or 8 are submitted in the claim segment.
Note: If field 3Ø8-C8 (Other Coverage Code) is populated with:
Value of 2 = Other coverage exists – payment collected; fields 341-HB, 342-HC and 431-DV are required and
must have values entered. Field 431-DV must not be zero ($0.00). The sum of all occurrences must not be zero.
Value of 3 = Other coverage billed – claim not covered; fields 471-5E and 472-6E are required and must have
values entered.
Value of 4 = Other coverage exists – payment not collected; fields 341-HB, 342-HC and 431-DV are required and
must have values entered. Field 431-DV must be zero ($0.00). The sum of all occurrences must be zero.
Value of 8 = Claim is billing for patient financial responsibility only; fields 353-NR, 351-NP and 352-NQ are required
and must have values entered.
Values of 5, 6, or 7 will be rejected.
DUR/PPS Segment – Situational
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification Ø8=DUR/PPS M
473-7E DUR/PPS Code Counter 1=Rx Billing (maximum of 9 occurrences) R
439-E4 Reason for Service Code DA=Drug-Allergy
DC=Drug-Disease (Inferred)
DD=Drug-Drug Interaction**
HD=High Dose (Maximum Daily Dose)
ID=Ingredient Duplication
R
8
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
LD=Low Dose (Minimum Daily Dose)
PG=Drug-Pregnancy
SX=Drug-Gender
TD=Therapeutic Duplication
SD=Suboptimal Drug/Indication
44Ø-E5 Professional Service Code ØØ=No intervention
MØ=Prescriber Consulted**
PE=Patient education/instruction
PØ=Patient consulted
RØ=Pharmacist consulted other source
MA=Medication Administered – indicates the
administration of a covered vaccine* **
441-E6 Result of Service Code 1A=Filled As Is, False Positive
1B=Filled As Is
1C=Filled, With Different Dose
1D=Filled, With Different Directions
1E=Filled, With Different Drug
1F=Filled, With Different Quantity
1G=Filled, With Prescriber Approval**
2A=Prescription Not Filled
2B=Not Filled, Directions Clarified
3C=Discontinued Drug
3E=Therapy Changed
3H=Follow-Up/Report
474-8E DUR/PPS Level of Effort 11=Level 1 (Lowest)
12=Level 2
13=Level 3
14=Level 4 (Highest)
*Indicates the claim billing includes a charge for administration of the vaccine; leave blank if dispensing vaccine without
administration.
**Indicates the code value accepted for member claims UPGRADED to the new adjudication system. All other
codes are still accepted for legacy Express Scripts plan sponsors that have not been upgraded to the new
system.
R
R
R
Compound Segment – Situational (Must be present on a compound claim)
(Will support only one transaction per transmission)
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 1Ø=Compound M
45Ø-EF Compound Dosage Form
Description Code
M
451-EG
Compound Dispensing Unit Form
Indicator
1=Each
2=Grams
3=Milliliters
Maximum 25 ingredients
447-EC Compound Ingredient Component
Count
M
488-RE Compound Product ID Qualifier Ø3=NDC M ―R‖
489-TE Compound Product ID At least 2 ingredients and 2 NDC #s. Number should M ―R‖
equal field 447-EC.
9
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖
M

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
448-ED Compound Ingredient Quantity M ―R‖
449-EE Compound Ingredient Drug Cost M ‖R‖
49Ø-UE Compound Ingredient Basis of Cost
Determination
R ―R‖
Clinical Segment – Situational
This segment may be required as determined by benefit design. When the segment is submitted, the fields defined
below are required.
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 13=Clinical M
491-VE Diagnosis Code Count Maximum count of 5 R
492-WE Diagnosis Code Qualifier R
424-DO Diagnosis Code R
Section II: Response Claim Billing (Out Bound)
Response Header Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
1Ø2-A2 Version Release Number DØ =Version D.Ø M
1Ø3-A3 Transaction Code B1=Billing M
1Ø9-A9 Transaction Count 1=One Occurrence
M
2=Two Occurrences
3=Three Occurrences
4=Four Occurrences
5Ø1-FI Header Response Status A=Accepted
M
R=Rejected
2Ø2-B2 Service Provider ID Qualifier Ø1=NPI M
2Ø1-B1 Service Provider ID NPI M
4Ø1-D1 Date of Service M
Response Message Segment - Optional
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 2Ø=Response Message M
5Ø4-F4 Message O
Response Insurance Segment – Mandatory
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 25=Response Insurance M
3Ø1-C1
Respons
524-FO
e 545-2F
Group ID
Plan ID
Network Reimbursement ID Network ID
O*
O*
R
Message
568-J7 Payer ID Qualifier O
Segment
-
10
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖
Mandato
ry
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 2Ø=Response Message M

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
569-J8 Payer ID O
3Ø2-C2 Cardholder ID R
*The Group ID (3Ø1-C1) or Plan ID (524-FO) field may be returned on paid claim responses until January 1, 2014.
Response Status Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 21=Response Status M
112-AN Transaction Response Status P=Paid
M
D=Duplicate of Paid
R=Reject
5Ø3-F3 Authorization Number RW
(Transaction
Response
Status = P)
51Ø-FA Reject Count Maximum count of 5 RW
(Transaction
Response
Status = R)
511-FB Reject Code RW
(Transaction
Response
Status = R)
546-4F Reject Field Occurrence Indicator RW
(If repeating field
is in error to
identify repeating
field occurrence)
13Ø-UF
132-UH
Additional Message Information
Count
Additional Message Information
Qualifier
Ø1-Ø9 = Free Form Text
1Ø = Next Available Fill Date (CCYYMMDD)
RW
(Additional
Message
(526-FQ) is used)
RW
(Additional
Message
(526-FQ) is used)
526-FQ Additional Message Information RW
(Additional text is
needed for
clarification or
detail)
11
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

131-UG
Additional Message Information
Continuity
Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
RW
(Current
repetition of
Additional
Message
Information
(526-FQ) is used
and another
repetition
(526-FQ) follows,
and text is
continuation of
the current)
549-7F Help Desk Phone Number Qualifier O
55Ø-8F Help Desk Phone Number O
987-MA URL R
Response Claim Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 22=Response Claim M
455-EM
4Ø2-D2
Prescription/Service Reference
Number Qualifier
Prescription/Service Reference
Number
1=Rx Billing
M
M
Response Pricing Segment – Mandatory
(This segment will not be included with a rejected response)
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 23=Response Pricing M
5Ø5-F5 Patient Pay Amount R
5Ø6-F6 Ingredient Cost Paid R
5Ø7-F7 Dispensing Fee Paid R
557-AV Tax Exempt Indicator RW (Required if
sender and/or
patient is tax
exempt and
exemption
applies to this
billing)
12
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Field # NCPDP Field Name Value Payer Usage
558-AW Flat Sales Tax Amount Paid RW
(Required if Flat
Sales Tax
Amount
Submitted
(481-HA) is
greater than zero
(Ø) or if Flat
Sales Tax
Amount Paid
(558-AW) is used
to arrive at
the final
reimbursement)
559-AX Percentage Sales Tax Amount Paid RW
(Required if
Percentage Tax
Amount
Submitted (482-
GE) is greater
than zero (Ø) or
Percentage Sales
Tax Rate Paid
(56Ø-AY) and
Percentage Sales
Tax Basis
Paid (561-AZ)
are used)
56Ø-AY Percentage Sales Tax Rate Paid RW
(Required if
Percentage Sales
Tax Amount Paid
(559-AX) is
greater than
zero (Ø)
561-AZ Percentage Sales Tax Basis Paid ØØ=Not specified
O
Ø2=Ingredient Cost
Ø3=Ingredient Cost + Dispensing Fee
521-FL Incentive Amount Paid O
566-J5 Other Payer Amount Recognized O
5Ø9-F9 Total Amount Paid R
522-FM Basis of Reimbursement
(Ø) R
Determination
523-FN Amount Attributed to Sales Tax O
512-FC Accumulated Deductible Amount O
513-FD Remaining Deductible Amount O
514-FE Remaining Benefit Amount O
13
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Field # NCPDP Field Name Value Payer Usage
517-FH Amount Applied to Periodic
Deductible
RW
(Patient Pay
Amount (505-F5)
includes
deductible)
518-FI
52Ø-FK
Amount of Co-pay
Amount Exceeding Periodic Benefit
RW
(Patient Pay
Amount (505-F5)
includes co-pay
as patient
financial
responsibility) O
Maximum
571-NZ Amount Attributed to Processor
O
Fee
575-EQ Patient Sales Tax Amount RW
(Used when
necessary to
identify Patient’s
portion of the
Sales Tax)
574-2Y Plan Sales Tax Amount RW
(Used when
necessary to
identify Plan’s
portion of Sales
Tax)
572-4U Amount of Coinsurance RW
(Patient Pay
Amount (5Ø5-F5)
includes
coinsurance as
patient financial
responsibility)
577-G3 Estimated Generic Savings RW
(Patient selects
brand drug when
generic was
available)
128-UC
Spending Account Amount
Remaining
RW
(If known when
transaction had
spending account
dollars reported
as part of patient
pay amount)
14
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Field # NCPDP Field Name Value Payer Usage
129-UD Health Plan-Funded Assistance
Amount
134-UK
Amount Attributed to Product
Selection/Brand Drug
RW
(Patient meets
the plan-funded
assistance criteria
to reduce Patient
Pay Amount
(5Ø5-F5)
RW
(Patient Pay
Amount (5Ø5-F5)
includes an
amount that is
attributable to
patient’s selection
of a Brand drug)
Response DUR/PPS Segment - Situational
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 24=Response DUR/PPS M
567-J6 DUR/PPS Response Code Counter Maximum 3 occurrences supported RW
(Reason for
Service Code
(439-E4) is used)
439-E4 Reason for Service Code AT=Additive Toxicity*
O
DA=Drug-Allergy
DC=Drug-Disease (Inferred)
DD=Drug-Drug Interaction*
ER=Overuse
HD=High Dose (Maximum Daily Dose)
ID=Ingredient Duplication
LD=Low Dose (Minimum Daily Dose)
PG=Drug-Pregnancy
SX=Drug-Gender
TD=Therapeutic Duplication
SD = Suboptimal Drug/Indication
528-FS Clinical Significance Code O
529-FT Other Pharmacy Indicator O
53Ø-FU Previous Date of Fill O
531-FV Quantity of Previous Fill O
532-FW Database Indicator O
533-FX Other Prescriber Indicator O
544-FY DUR Free Text Message O
*Indicates the code value returned in response for member claims UPGRADED to the new adjudication system.
15
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Response Coordination of Benefits/Other Payers – Situational
(This segment will not be included with a rejected response)
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 28=Response Coordination of Benefits/Other Payers M
355-NT Other Payer ID Count Maximum count of 3 M
338-5C Other Payer Coverage Type M
339-6C Other Payer ID Qualifier RW
(Other Payer ID
(34Ø-7C) is used)
34Ø-7C Other Payer ID RW
(Other insurance
information is
available for
COB)
991-MH
Other Payer Processor Control
Number
RW
(Other insurance
information is
available for
COB)
356-NU Other Payer Cardholder ID RW
(Other insurance
information is
available for
COB)
992-MJ Other Payer Group ID RW
(Other insurance
information is
available for
COB)
142-UV Other Payer Person Code RW
(Needed to
uniquely identify
the family
members within
the Cardholder
ID, as assigned
by other payer)
127-UB
Other Payer Help Desk Phone
Number
RW
(Needed to
provide a support
telephone
number of other
payer to the
receiver)
Section III: Reversal Transaction (In Bound)
Transaction Header Segment - Mandatory
16
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Field # NCPDP Field Name Value Payer Usage
1Ø1-A1 BIN Number ØØ3858 (or as used on original claim submission) M
1Ø2-A2 Version Release Number DØ=Version D.Ø M
1Ø3-A3 Transaction Code B2=Reversal M
1Ø4-A4 Processor Control Number A4 (or as used on original claim submission) M
1Ø9-A9 Transaction Count 1=One Occurrence, one reversal per B2 transmission M
2Ø2-B2 Service Provider ID Qualifier Ø1=NPI M
2Ø1-B1 Service Provider ID NPI M
4Ø1-D1 Date of Service M
11Ø-AK Software Vendor/Certification ID M
Note: Reversal window is 9Ø days.
Insurance Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification Ø4=Insurance M
3Ø2-C2 Cardholder ID ID assigned to the cardholder M
Claim Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification Ø7=Claim M
445-EM Prescription /Service Reference 1=Rx Billing
M
Number Qualifier
4Ø2-D2 Prescription/Service Reference
M
Number
436-E1 Product/Service ID Qualifier Ø3=National Drug Code R
4Ø7-D7 Product/Service ID R
4Ø3-D3 Fill Number R
3Ø8-C8 Other Coverage Code Ø=Not Specified
R
1=No other coverage identified
2=Other coverage exists-payment collected*
3=Other coverage exists-this claim not covered*
4=Other coverage exists-payment not collected*
8=Claim is a billing for patient financial responsibility
only*
*Please use Other Coverage Code submitted on the original COB transaction.
Coordination of Benefits/Other Payments Segment – Situational
(Will support only one transaction per transmission)
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification Ø5=COB/Other Payments M
337-4C Coordination of Benefits/Other Maximum count of 3
M
Payments Count
338-5C Other Payer Coverage Type M
17
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖

Express Scripts, Inc.
NCPDP Version D.0 Payer Sheet
Commercial
Section IV: Reversal Response Transaction (Out Bound)
Response Header Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
1Ø2-A2 Version Release Number DØ=Version D.Ø M
1Ø3-A3 Transaction Code B2=Reversal M
1Ø9-A9 Transaction Count 1=One Occurrence, per B2 transmission M
5Ø1-FI Header Response Status A=Accepted
M
R=Rejected
2Ø2-B2 Service Provider ID Qualifier Ø1=NPI M
2Ø1-B1 Service Provider ID NPI M
4Ø1-D1 Date of Service M
Response Message Segment - Situational
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 2Ø=Response Message M
5Ø4-F4 Message O
Response Status Segment - Situational
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 21=Response Status M
112-AN Transaction Response Status A=Approved
M
R=Rejected
51Ø-FA Reject Count Maximum count of 5 RW
(Transaction
Response
Status=R)
511-FB Reject Code RW‖R‖
(Transaction
Response
Status=R)
549-7F Help Desk Phone Number Qualifier O
55Ø-8F Help Desk Phone Number O
Response Claim Segment - Mandatory
Field # NCPDP Field Name Value Payer Usage
111-AM Segment Identification 22=Response Claim M
455-EM
4Ø2-D2
Prescription/Service Reference
Number Qualifier
Prescription/Service Reference
Number
1=Rx Billing
M
M
18
Payer Usage: M=Mandatory, O=Optional, R=Required by ESI to expedite claim processing,
"R"=Repeating Field, RW=Required when; required if ―x‖, not required if ―y‖